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Insurance Quotation

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Proposal For Motor Vehicle Insurance

Customer Information

Name of proposer in full
Nationality
Address
Occupation
Phone Number
Age
Date of Birth

Particulars Of Motor Vehicles To Be Insured

VIN
Make
Type of Model
Year
Type of Body
Seating
Horse Power
Date of Purchase
License Plate
Price Paid

Insurance Coverage

Coverage Required
Please state the period of insurance required
From:
To:

Vehicle Usage

Will the vehicle be used solely for social, domestic and pleasure purpose? If not, will the vehicle also be used:
(a) Solely by you in person for your business or profession?
(b) On your business by your employees or other persons?
(c) For carriage of goods or samples in connection with your trade or business?
(d) For Commercial Traveling in your business?
(e) In connection with the Motor Trade?
(f) For uses other than (a) to (e) above ?
Please describe if yes:

Vehicle Ownership

(a) Are you the sole owner of the Vehicle described in Step 2 and is it registered in your name?
If not please state particulars of ownership and registration
(b) Is the vehicle the subject of a Hire Purchase Agreement?
If so state the name and address of the Finance Company

Additional Drivers

Is the Vehicle likely to be driven by any person other than the proposer?
If so, please give details (a), (b), (c) and (d) for each additional driver.
Additional Driver (1)
Additional Driver (2)
(a) Name
(a) Name
(b) Age
(b) Age
(c) Occupation
(c) Occupation
(d) If paid driver
(d) If paid driver

Drivers License Information

Proposer Info:

Driver License Number
Years Driving (Other than a motorcycle)
Have you been driving within the past twelve months
Driver License Type
Expire Date

Additional Driver (1):

Driver License Number
Years Driving (Other than a motorcycle)
Have you been driving within the past twelve months
Driver License Type
Expire Date

Additional Driver (2):

Driver License Number
Years Driving (Other than a motorcycle)
Have you been driving within the past twelve months
Driver License Type
Expire Date

Documents (Scanned)

(a) Title Papers:



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(b) Utility Bill (less than 3 months old):



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(c) Social Security card:



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(d) Valid drivers license or permit:



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(e) Picture of vehicle:



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Accept Terms and Agreement

I/We hereby warrant the truth of the above statements (and in the case of vehicles used for commercial purposes the statement overleaf.) I/We have withheld no information whatsoever which might tend in any way to increase the risk of the company or influence the acceptance of this proposal. I/We agree that this Proposal shall be the basis of the contract between we/us and the Company and I/We further agree to accept a Policy subject to its conditions.
Note that by entering your name and uploading this form, that is your digital signature and is legally bind.
Date:
Signature (type name)
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